MEDICARE: LONE STAR BACK PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1841419843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONE STAR BACK PA

Provider Business Mailing Address
First Line	:	PO BOX 226656
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75222-6656
Country	:	US
Telephone Number	:	214-943-9431
Fax Number	:	214-943-9407

Provider Business Practice Location Address
First Line	:	1002 MONTGOMERY ST STE 200
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76107-2693
Country	:	US
Telephone Number	:	214-943-9431
Fax Number	:	214-943-9407

Authorized Official
Title or Position	:	OWNER
Name	:	SHAWN HENRY
Credential	:	DO
Telephone Number	:	214-943-9431

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	08/22/2020

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Directions to “LONE STAR BACK PA ” Practice Location

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